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SAmental health2020-09-22

Coroner's Finding: NOONAN Ricky Dale

54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking

A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…

psychiatryemergency medicinecommunicationsystemhaloperidol
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagno…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol
VIChospital2020-09-07

Finding into death of Ms TP

37y · Female·Hypoxic ischaemic encephalopathy as a direct result of neck compression

Ms TP, a 37-year-old woman of Indian origin living in Victoria, died from hypoxic ischaemic encephalopathy resulting from ligature strangulation (neck compression). She was admitted to ICU in cardiac arrest and died nine…

intensive careemergency medicine
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …

emergency medicineintensive carediagnosticcommunicationparacetamol
NSW2020-09-04

Inquest into the death of Stephen Pitty

70y · Male·Complications of Ischaemic cardiomyopathy and Chronic Obstructive Pulmonary Dise…

Stephen Pitty, aged 70, died from complications of ischaemic cardiomyopathy and chronic obstructive pulmonary disease whilst in custody at Long Bay Correctional Centre. He had significant cardiac history including seven …

cardiologyrespiratory medicine
TAShospital2020-09-02

Coroner's Finding: Breen, Kylie Anne

40y · Female·hypoxic brain injury and acute lung injury; multiple drug toxicity with oxycodon…

A 40-year-old woman with advanced multiple sclerosis died from drug toxicity and hypoxic brain injury following intentional overdose and gas inhalation. She had completed an Advance Care Directive (ACD) 12 months prior r…

emergency medicineintensive carecommunicationsystemoxycodone
VIChome2020-08-24

Finding into death of Wayne Laurence Marshall

54y · Male·Methadone use in a man with asthma and sarcoidosis of the lungs

Wayne Marshall, a 54-year-old registered nurse, died from respiratory depression caused by methadone use in the context of underlying asthma and pulmonary sarcoidosis. He was found gasping for air at home and could not b…

emergency medicineintensive caremethadone
WAcommunity2020-08-18

Inquest into the Death of Jessica Lesley JACKSON

18y · Female·multi-organ failure due to combined effects of environmental exposure (hyperther…

Jessica Jackson, 18, died from multi-organ failure due to combined hyperthermia and dehydration while weight-cutting for an amateur Muay Thai fight. She lost approximately 9 kg in the final week through water-loading, de…

emergency medicinesports medicinediagnosticsystem
VIChome2020-08-17

Finding into death of Benjamin James Browne

29y · Male·Incised injury to the neck

Benjamin Browne, 29, died from a neck laceration sustained during acute behavioural disturbance in August 2018. He had diagnosed major depression with anxiety, prescribed mirtazapine but attended only two psychology sess…

general practicepsychologysystemcommunicationmirtazapine
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…

gastroenterologygeneral practicecommunicationsystemfleet enema
TAShospital2020-08-12

Coroner's Finding: Maynard, Grant Godfrey

60y · Male·multi-organ failure due to injuries sustained in motor vehicle accident, specifi…

A 60-year-old Aboriginal man with significant comorbidities (cardiomyopathy, cirrhosis, renal failure, diabetes) presented to ED following a motor vehicle accident at low speed. Despite chest imaging showing pleural effu…

emergency medicinegeneral medicinediagnosticdelaydoxycycline
VICaged care2020-07-22

Finding into death of Dorothy Boyle

92y · Female·Complications of a fractured left femur (operated), sustained in a fall

Dorothy Lorraine Boyle, aged 92, died from complications of a left femoral fracture sustained in a fall at an aged care facility. She fell while attempting to push out a wandering dementia-affected resident who had enter…

geriatric medicineemergency medicinesystemprocedural
NThospital2020-07-17

Inquest into the death of Ishmael Nawirridj

51y · Male·Multiple organ failure due to Influenza A pneumonia, in the context of chronic k…

Ishmael Nalaiyir Nangarid, a 51-year-old Aboriginal man with complex medical history including myasthenia gravis, chronic kidney disease, COPD, and ischaemic heart disease, died from multiple organ failure due to Influen…

intensive carerespiratory medicinemedicationmeropenem
SAhospital2020-07-16

Coroner's Finding: GRAEFE Phillip Brian

62y · Male·Multi-organ failure due to paraquat ingestion

A 62-year-old man with diabetes, renal failure, and hypertension died from multi-organ failure following intentional ingestion of approximately 100-150ml of paraquat. He had recently assumed sole responsibility for the f…

toxicologyemergency medicineparaquat
SAhospital2020-07-09

Coroner's Finding: SHAW Laurel Jean

84y · Female·multi-organ failure arising from Staphylococcal septicaemia

Laurel Jean Shaw, aged 84, died from multi-organ failure secondary to Staphylococcal septicaemia. She was detained under a Mental Health Act order for Lewy Body Dementia when she developed MRSA pneumonia and sepsis on 15…

intensive carepsychiatry
VIChospital2020-07-07

Finding into death of Marek Koziol

61y · Male·Injuries sustained in motor vehicle collision (pedestrian)

A 61-year-old legally blind man was struck by a motor vehicle while crossing a busy highway with his guide dog. He sustained severe head injuries including subarachnoid and subdural haemorrhage, and diffuse axonal injury…

trauma surgeryintensive care
VIChospital2020-07-01

Finding into death of Baby M

3y · Male·Hypoxic ischaemic encephalopathy complicating drowning

A 3-year-old boy drowned in a home swimming pool after the pool gate failed to latch properly due to wear and lack of maintenance. The gate did not comply with Australian Standards requiring self-closing and self-latchin…

emergency medicineintensive caresystemdelay
VIChospital2020-06-29

Finding into death of Colleen Elizabeth Fermanian

45y · Female·Blunt force trauma to the head

Colleen Fermanian, 45, died from blunt force trauma to the head sustained on 24-25 March 2017. She had a history of heavy alcohol use and advanced liver disease. The circumstances of her injury remain unclear—it could ha…

emergency medicineintensive caremidazolam
QLDcommunityPodcast2020-06-26

Nyholt, Nicole Sonia and Clark, Margaret Louisa

Female·Burns due to gas explosion due to motor vehicle collision with building

A 60-year-old man with a long-standing history of seizures experienced an epileptic seizure while driving and lost control of his vehicle. It collided with an LPG gas cylinder outside a café, triggering an explosion that…

emergency medicineneurologycommunicationsystem
SAhospital2020-06-25

Coroner's Finding: KARTINYERI Laura Rose

44y · Female·multi-organ failure and polypharmaceutical overdose on a background of severe ch…

Laura Rose Kartinyeri, aged 44, died from multi-organ failure and polypharmaceutical overdose on a background of severe COPD. She had a long history of substance abuse, non-compliance with treatment, and hospital present…

respiratory medicineintensive carepregabalin
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